Accident

Date of Incident(Required)

Time of Incident(Required)

Employee Start Time(Required)

Incident Information

Employee Name(Required)

Please Enter Employee Name

First Last

Which branch do you work out of?(Required)

Address where accident/incident/injury occurred(Required)

Street Address City State

Incident Involved (select all that apply)(Required)

Personal Injury

Another Vehicle

Company Vehicle

Grass/Ruts

Fixed Object

Overhead Wire

Pedestrian

Other

Conditions

Ground Conditions (select all that apply)(Required)

Grass

Concrete

Asphalt

Gravel

Dirt

Weather Conditions (select all that apply)(Required)

Sunny

Partly Cloudy

Dark

Rain

Foggy

Snow/Ice

Incident Questionnaire

Are you self-reporting accident/injury?(Required)

If not, who is completing this report on employee's behalf?(Required)

Was this injury reported right away?(Required)

When was this reported?(Required)

Did this accident/incident occur on a customer's site?(Required)

Customer # where the incident occurred(Required)

Were you operating/driving equipment at the time of the accident?(Required)

Were you pulling a trailer at the time of the incident?(Required)

Was a police report filed?(Required)

Which police agency responded?(Required)

Were you issued a citation?(Required)

Was the other driver issued a citation?(Required)

Were there passengers in the other vehicle?(Required)

How Many Passengers Were in the Car?(Required)

Did you personally suffer any injuries?(Required)

Type of Injury(Required)

Specific Body Part(Required)

Which side of body?(Required)

Other type of injury(Required)

What body part was injured?(Required)

What of burn?(Required)

Please describe who was injured and what type of injury?(Required)

Do you need to seek medical attention?(Required)

What object (tools, equipment, etc) contributed to the injury?(Required)

Do you need to be transported to a medical facility?(Required)

Was our vehicle/equipment damaged?(Required)

Was claimant's property/vehicle damaged?(Required)

Did any vehicle(s) have to be towed away?(Required)

Were pictures taken at the accident scene?(Required)

Were there any witnesses?(Required)

Service Sanitation Vehicle

Type of Vehicle(Required)

Truck Number(Required)

Trailer Number(Required)

Information From Other Party

Claimant's Name

Claimant's Phone

Claimant's Address

Street Address City State

Vehicle Year(Required)

Vehicle Make(Required)

Vehicle Model(Required)

License Plate #(Required)

Passenger Names

Please include the names of any passengers in the other vehicle, not including the driver..

Please Describe Damage(Required)

Claimant's Insurance Information

Insurance Carrier

Insurance Policy Number

Upload Photo of Claimant's Insurance Card

Max. file size: 512 MB.

Additional Claimants

Were there additional parties involved besides the contact listed above?(Required)

Claimant 2 Name

Claimant 2 Phone

Claimant 2 Address

Street Address City State

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 License Plate #

Vehicle 2 Passenger Names

Please include the names of any passengers in the other vehicle, not including the driver..

Claimant 2's Insurance Information

Vehicle 2 Insurance Carrier

Insurance Policy Number

Describe Claimant 2 Property Damage (Required)

Witness Information

Witness 1 Name

First Last

Witness 1 Phone

Witness 2 Name

First Last

Witness 2 Phone

Incident Description

Please describe this incident, injury, or accident in full detail.(Required)

What could have been done to prevent this accident, injury, or incident?(Required)

Seeking Medical Attention Acknowledgment

Failure to notify Manager/HR(Required)

I understand that I am not to go to the ER or seek medical attention on my own unless I feel it's a life threatening condition. If I choose to seek medical attention on my own, I will be financially responsible for any incurred costs and return-to-work status if it's not a life-threatening condition.

Medical Declination Consent

No treatment at this time(Required)

I understand the incident that I’m reporting entitles me to receive medical attention. Understanding this right, I am declining medical attention at this time.

If I need medical attention at a later time...(Required)

I understand I hold the right to seek medical treatment later; however, I must notify my manager or HR to coordinate treatment.

Failure to notify Manager/HR(Required)